Employment Application

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Full Name *

Address *

City *

State *

Zip *

Phone Number *

Email Address *

Date Available to Start *

Social Security Number *

Salary Requirements *

If you are under 18 years of age, can you provide a work permit?

If no, please explain

Have you ever worked for this company?

If yes, when?

Are you legally allowed to work in the United States?

Type of employment desired

Have you ever pleaded guilty, no contest or been convicted of a crime?

If yes, give dates and details

Answering yes to these questions does not constitute an automatic rejection of employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Driver’s license number

State

Date of Birth

Education History

Name & Location of High School

Did you graduate?

Name & Location of College

Years Attended

Degrees completed

Other Subjects Studied

Trade, Business or Correspondence School

Years Attended

Summarize Your Special Skills or Qualifications

Previous Employment (begin with most recent position)

Dates of Employment

Position(s) held

Company Name

Address

City

State

Zip

Phone

Supervisor

Title

Responsibilities

Starting Salary and Title

Ending Salary and Title

Reason for Leaving

May we contact this employer for a reference?

Dates of Employment

Position(s) held

Company Name

Address

City

State

Zip

Phone

Supervisor

Title

Responsibilities

Starting Salary and Title

Ending Salary and Title

Reason for Leaving

May we contact this employer for a reference?

Dates of Employment

Position(s) held

Company Name

Address

City

State

Zip

Phone

Supervisor

Title

Responsibilities

Starting Salary and Title

Ending Salary and Title

Reason for Leaving

May we contact this employer for a reference?

Agreement and Signature

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements of this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability- related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”